For Each Hour of Clinical Time, Docs Spend 2 on Desk Work

Time-and-motion study of 57 doctors in ambulatory settings

Physicians in ambulatory settings spent nearly 2 hours on clerical work for every 1 hour they dedicated to direct clinical face time with patients during the clinic day, according to a study published online in Annals of Internal Medicine Monday.

Citing this and other study results, two physicians are calling for potential healthcare reform.

"We need to reconsider whether spending 2 hours on desk work for every hour of patient care is the way we want to distribute [doctors'] time," the study's lead author, Christine Sinsky, MD, vice president of professional satisfaction at the American Medical Association, told MedPage Today. "It's time for us to stop doing that in healthcare, because our patients will get more value if physicians spend the majority of our time directly caring for them."

"These data document what physicians have long believed: The work of physicians has changed dramatically in recent years, at least partially due to EHRs [electronic health records]," Susan Hingle, MD, director of faculty development at SIU Healthcare in Springfield, Ill., wrote in an editorial accompanying the study. "Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the healthcare system that will redirect our focus from the computer screen to our patients."

The 57 physicians observed in the study spent 27% of their total daily time on direct clinical face time with patients -- versus 49.2% on health records and desk work.

While in the examination room, the physicians dedicated 52.9% of their time to face-face interactions, and 37% to records and desk work. The latter figure is consistent with two studies showing that physicians spent one-third of patient time using records; bothstudies were published within the last 5 years.

Most (3 of 4 hours) of the overall health record and desk work time observed in the new study was dedicated to documentation and review tasks.

"We can very clearly state that physicians are spending more time on data entry and clerical tasks than directly caring for patients," said Sinsky, who is also a general internist in Dubuque, Iowa.

The researchers monitored 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics for a total of 430 hours over 5 weeks in 2015, applying a time-and-motion methodology to this direct-observation study. The team also developed and ascribed task codes. The specialties were selected to include two types of primary care practices, one medical specialty, and one surgical specialty, and to develop a sample "representative of a large and inclusive number of physicians," the authors wrote. They worked with 16 medical practices across four states.

"Our goal was to describe time allocation and practice characteristics (including EHR use and documentation support services) for physicians in the era of EHRs and federal incentive and penalty programs."

Added Sinsky: "The study allows us to really see what's happening in a physician's day, and see the extent to which physicians are spending time on deskwork and at the computer, rather than caring for patients."

Limitations included a sample too small to compare across specialties, self-selected medical practices, and minimal hours observing documentation assistant services.

Hingle said that despite the limitations the study provides unique quantitative support to anecdotal data, including her own professional experience. "I hope people don't discount the findings, because they really are important; they really are validating," Hingle, also an internal medicine physician, told MedPage Today.

"Is it enough to draw huge conclusions? Probably not. But this is just validating what physicians have been saying ... It's the first step in people saying, 'Oh this is what we are talking about.' Hopefully future studies can be designed with a larger number of patients."

The researchers called for more research into documentation support's impact on direct clinical face time with patients, as well as EHR and desk work's contextual "cost" regarding cognitive load and restrictions to adapting workflow to patient needs.

"This activity observed should not be assumed to be good or bad," the authors wrote. "Rather, it needs to be linked to quality, financial, and professional satisfaction outcomes for a full understanding of the activities that are critical to achieving superior clinical outcomes versus the activities that are required only for administrative and regulatory purposes or that represent a source of inefficiency or a waste of time, talent, or resources."

Four of the study's coauthors report working for the American Medical Association, which funded the study. Sinsky reports serving on the advisory committee for healthfinch, a practice automation start-up.

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